Dr. Smith's ECG Blog

APRIL 18, 2024

I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Non-STEMI guidelines call for “urgent/immediate invasive strategy is indicated in patients with NSTE-ACS who have refractory angina or hemodynamic or electrical instability,” regardless of ECG findings.[1]

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STEMI Chest Pain Myocardial Infarction Blog 121

Dr. Smith's ECG Blog

MARCH 31, 2024

The interventional cardiologist then canceled the activation and returned the patient to the ED without doing an angiogram ("Not a STEMI"). I advised that perhaps posterior leads would help to persuade the interventionalist, since the 2022 ACC recommendations include posterior STEMI as a formal STEMI equivalent, but only officially by 0.5

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Chest Pain STEMI Ischemia Myocardial Infarction 111

Dr. Smith's ECG Blog

JUNE 15, 2023

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.

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STEMI Chest Pain Stenosis Outcomes 98

Dr. Smith's ECG Blog

DECEMBER 22, 2022

Take home messages: 1- In STEMI/NSTEMI paradigm you search for STE on ECG. If this patient was managed according to the STEMI/NSTEMI paradigm (although he would be a candidate for early invasive treatment), he would probably be taken to the cath lab hours later. Here is the post-intervention angiogram and post-PCI ECG. 2021.21026.

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STEMI Chest Pain Myocardial Infarction Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 10, 2025

If we took this as the gold standard, we would conclude that the computer interpretation was safe and accurate at least accurate enough to not miss STEMI, and that physicians should not be interrupted to interpret it, because there would be no change in patient management. What is the gold standard for ECG interpretation: patient outcome!!!

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Chest Pain Outcomes STEMI Electrocardiogram 89

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]

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Chest Pain STEMI Electrocardiogram Ischemia 119

Dr. Smith's ECG Blog

AUGUST 16, 2024

Its hard to measure the STE in I exactly with the moving baseline, but there is almost certainly not enough STE to meet STEMI criteria. The ACC recognizes these findings as formal STEMI equivalents (though they do not define how to find them). They are symmetric, fat, convex on both sides, etc.

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Chest Pain STEMI Blog 112

Dr. Smith's ECG Blog

MAY 23, 2023

Notice on the right side of the image how the algorithm correctly measures STE sufficient in V1 and V2 to meet STEMI criteria in a man older than age 40. As most would agree, this ECG shows highly specific findings of anterolateral OMI, even with STEMI criteria in this case. Thus, this is obvious STEMI(+) OMI until proven otherwise.

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Chest Pain STEMI Blog Stents 98

Ken Grauer, MD

FEBRUARY 3, 2024

Despite the absence of significant coronary stenosis on her post-arrest cath — the ECG in Figure-1 is clearly diagnostic of an extensive anterolateral STEMI ( presumably from acute LAD [ L eft A nterior D escending ] coronary artery occlusion). The rhythm in ECG #1 is regular and supraventricular at a rate of ~75/minute.

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Blog Cardiac Arrest STEMI Plaque 164

Dr. Smith's ECG Blog

AUGUST 19, 2023

This is diagnostic of infero-posterior OMI, but it is falsely negative by STEMI criteria and with falsely negative posterior leads (though they do show mild ST elevation in V4R). They were less likely to have STEMI on ECG, and more likely to be initially diagnosed as non-ACS. Figure-1: The initial ECG in today’s case.

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Chest Pain STEMI Myocardial Infarction Blog 98

Dr. Smith's ECG Blog

MARCH 4, 2024

Unknown algorithm The Queen gets it right Case 4 How unreliable are computer algorithms in the Diagnosis of STEMI? The patient's prehospital ECG showed that there was massive STEMI and these are hyperacute T-waves "on the way down" as they normalize. Pain was resolving. Diagnosed as Normal by the computer. Troponin negative.

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STEMI Blog Chest Pain Webinar 128

Frontiers in Cardiovascular Medicine

JANUARY 2, 2024

Background Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. Conclusion CPC quality control metrics affect STEMI mortality based on Killip class.

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Chest Pain Myocardial Infarction COVID-19 Catheterization Laboratory 59

Dr. Smith's ECG Blog

SEPTEMBER 29, 2024

This certainly looks like an anterior STEMI (proximal LAD occlusion), with STE and hyperacute T-waves (HATW) in V2-V6 and I and aVL. How do you explain the anterior STEMI(+)OMI immediately after ROSC evolving into posterior OMI 30 minutes later? This caused a type 2 anterior STEMI. The April 8, 2022 post by Drs.

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Cardiac Arrest STEMI Ischemia SCAD 110

Dr. Smith's ECG Blog

AUGUST 2, 2024

This was a machine read STEMI positive OMI. The meaning of this quote is that at times, something as obvious as the dramatic anterior lead ST elevation that we see in today's tracing is not the result of an acute LAD STEMI. His ECG is shown below. Pretty obvious anterior current of injury. What would you guess is the culprit artery?

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STEMI Ischemia Blog Chest Pain 119

Dr. Smith's ECG Blog

OCTOBER 8, 2024

Subtle as a STEMI." (i.e., Here is the bottom line of the article: It is widely believed that hyperacute T-waves are a transitional state preceding ST Elevation 1–4 Thus, it is tempting to postulate that early cases of OMI will eventually evolve to STEMI; yet, our data contradicts that notion. This one is easy for the Queen.

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Cardiac Arrest Myocardial Infarction STEMI Cardiogenic Shock 123

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. The two cases were considered: Patient 1 was recognized by the ED provider and the cardiologist as having resolved “STEMI”. He wrote most of it and I (Smith) edited.

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Chest Pain STEMI Echocardiogram Stents 116

Dr. Smith's ECG Blog

APRIL 22, 2024

Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). As far as I can tell, there is only one randomized trial of immediate vs. delayed intervention for transient STEMI. Labs ordered but not yet drawn.

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Chest Pain Myocardial Infarction Anatomy Angina 118

DAIC

APRIL 6, 2024

The Minneapolis Heart Institute Foundation (MHIF) is presenting leading research focused on trends in ST-elevation myocardial infarction (STEMI), the most severe form of a heart attack, at the American College of Cardiology’s Annual Scientific Session (ACC.24), 24), being held April 6-8 in Atltanta, GA.

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Heart Attack Heart attacks Risk Factors Research 52

Coronary Artery Disease Journal

OCTOBER 30, 2023

Methods Clinical data from patients admitted to the cardiology division between 2018 and 2022, who were diagnosed with AMI and underwent an IPF testing. Results Among the 277 patients diagnosed with AMI who underwent IPF testing, 113 had (STEMI) and 164 had (NSTEMI). Notably, among STEMI patients, those with IPF ≥ 4.2%

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Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Here they are: Patient 1, ECG1: Zoll computer algorithm stated: " STEMI , Anterior Infarct" Patient 2, ECG1: Zoll computer algorithm stated: "ST elevation, probably benign early repolarization." He diagnosed anterior "STEMI" and activated the cath lab. 25 minutes later, EMS called back with this new ECG: Super obvious STEMI(+) OMI.

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STEMI Chest Pain Blog Pericarditis 125

Dr. Smith's ECG Blog

OCTOBER 17, 2024

The prehospital and ED computer interpretation was inferior STEMI: There’s normal sinus rhythm, first degree AV block and RBBB, normal axis and normal voltages. The paramedic notes called STEMI into question: “EMS disagree with monitor for STEMI callout. Vitals were normal except for oxygen saturation of 94%. Vitals were normal.

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Chest Pain STEMI Pulmonary Embolism 73

Ken Grauer, MD

APRIL 18, 2023

P utting I t A ll T ogether : After correcting for LA-LL lead reversal — ECG # 1a shows sinus rhythm — LVH — and an acute infero-postero STEMI with acute RV involvement. PEARL # 3: In the absence of an anterior STEMI — acute inferior MI is the result of either acute RCA or LCx ( L eft C ircumfle x ) coronary occlusion.

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Blog STEMI Chest Pain Physiology 78

Dr. Smith's ECG Blog

SEPTEMBER 29, 2023

In the available view of the sinus rhythm, we see normal variant STE which probably meets STEMI criteria in V4 and V5. In other words, the inferior "ST elevation" is due to the abnormal rhythm, and does not signify OMI or STEMI in any way. This situation has been named "Emery phenomenon." YOU TOO CAN HAVE THE PM Cardio AI BOT!!

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Chest Pain Tachycardia STEMI Blog 130

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

STEMI MINOCA versus NSTEMI MINOCA STEMI occurs in the presence of transmural ischaemia due to transient or persistent complete occlusion of the infarct-related coronary artery. This has resulted in an under-representation of STEMI MINOCA patients in the literature. From Gue at al. Circulation. 2017;135(16):1490–3.

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Coronary Angiogram Plaque Thrombosis STEMI 109

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Immediate versus delayed invasive intervention for non-stemi patients. Is there anything else on the tracing to corroborate inferior OMI?

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Myocardial Infarction Chest Pain STEMI Blood Pressure 123

Dr. Smith's ECG Blog

MARCH 22, 2024

This is documented as a STEMI in the clinical notes and in the cath report, but certainly does not meet STEMI criteria and is therefore an NSTEMI by definition. For national registry purposes, this will be incorrectly classified as a STEMI.) Most STEMI have peak cTnI greater than 10.0. Large STEMI are approximately 30-80.

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Chest Pain STEMI Bradycardia Ischemia 114

Dr. Smith's ECG Blog

MAY 30, 2023

There is an obvious inferior posterior STEMI(+) OMI. Methods Retrospective study of consecutive inferior STEMI , comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. The April 17, 2022 post ( Leads V1,V2 misplacement ). How would one tell?

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Chest Pain Myocardial Infarction STEMI Cardiogenic Shock 97

Ken Grauer, MD

MAY 20, 2023

In the October 15, 2022 post of Dr. Smith's ECG Blog — Drs. Smith and Meyers in their October 15, 2022 post on Precordial Swirl. Figure-3: Selected sets of V1,V2 leads from the examples of Precordial Swirl provided in the October 15, 2022 post in Dr. Smith's ECG Blog. What is P recordial S wirl ?

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Blog Chest Pain Ischemia STEMI 144

Dr. Smith's ECG Blog

JUNE 1, 2022

This is guideline approved by both ACC/AHA and by European guidelines. == Comment by K EN G RAUER, MD ( 6/1/2022 ): == I found serial evaluation of sequential tracings in today's case to be subtle — yet highly insightful. A patient with active chest pain and an otherwise unexplained elevated troponin should go to the cath lab.

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Chest Pain STEMI Myocardial Infarction Bradycardia 52

Dr. Smith's ECG Blog

SEPTEMBER 5, 2024

It has been estimated that in the aggregate, they occur at a rate of about 3 per 1000 patients with acute MI, and most of these events occur in patients with STEMI. A mong patients with STEMI, ventricular septal rupture is the most common and free wall rupture is the least common.

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Cardiogenic Shock Chest Pain Pericarditis Myocardial Infarction 109

Ken Grauer, MD

OCTOBER 25, 2024

It may look identical t o the ST-T wave appearance seen after a STEMI with marked troponin elevation, that has now reperfused ( be this reperfusion spontaneous — or by treatment with PCI or thrombolytics ). A DDENDUM ( 10/26/2024 ) : I excerpted what follows below from My Comment in the August 12, 2022 post in Dr. Smith's ECG Blog ). =

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Blog Chest Pain STEMI Cardiogenic Shock 95

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. She was out walking her dog when she developed sudden dizziness and light-headedness. When EMS found her, she was dyspneic and diaphoretic.

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Cardiogenic Shock Ultrasound Tachycardia Pulmonary 128

Dr. Smith's ECG Blog

JANUARY 3, 2022

Step 1 to missing posterior MI is relying on the STEMI criteria. A prospective validation of STEMI criteria based on the first ED ECG found it was only 21% sensitive for Occlusion MI, and disproportionately missed inferoposterior OMI.[1] But it is still STEMI negative. A 15 lead ECG was done (below). In a study last year, 14.4%

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STEMI Myocardial Infarction Chest Pain Ischemia 52

Dr. S. Venkatesan MD

JANUARY 14, 2024

Will evolve into STEMI by prothrombotic trigger of lytic agent ECG will get normalised with clinical stability in some Nothing happens. Majority of Wellens end up as NSTEMI, statistics tells us about 20% of them can be STEMI in incognito mode demanding lysis or emergency PCI. BMC Cardiovasc Disord 22 , 176 (2022). Reference 1.

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Anatomy Angina STEMI Thrombosis 52

Dr. Smith's ECG Blog

DECEMBER 29, 2023

But because there was no new ST elevation, the ECG was signed off as “STEMI negative” and the patient waited to be seen. But the ECG still doesn’t meet STEMI criteria. It was therefore interpreted as “no STEMI” and the patient was treated with dual anti-platelets and referred to cardiology as “NSTEMI.” the cardiologist 5.

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Chest Pain STEMI Myocardial Infarction Electrocardiogram 70

Dr. Smith's ECG Blog

JANUARY 6, 2024

Here, I do not see OMI (although the ECG is falsely STEMI positive with just over 1 mm STE in V1 and about 2.5 The April 17, 2022 post ( Leads V1,V2 misplacement ). The May 5, 2022 post ( LA-RA reversal ). The May 24, 2022 post ( LA-LL reversal ). The May 26, 2022 post ( LA-LL reversal ). What do you think?

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Blog Ischemia Tachycardia STEMI 111

Dr. Smith's ECG Blog

JUNE 19, 2024

His EKG with worse pain now shows enough ST elevation to meet STEMI criteria. The EKG was read by the conventional computer algorithm as diagnostic of “ACUTE MI/STEMI”. The patient started receiving medications for “STEMI” (including heparin!!!) The patient started receiving medications for “STEMI” (including heparin!!!)

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Chest Pain Pericarditis Pacemaker STEMI 60